血栓弹力图评价严重脓毒症凝血功能紊乱的研究

目的:研究严重脓毒症患者各阶段的血栓弹力图(thromboelastography,TEG)和常规凝血功能表现,评价TEG对严重脓毒症并发弥散性血管内凝血(DIC)的诊断价值。方法:选择北京安贞医院EICU和RICU严重脓毒症患者37例,根据显性DIC评分结果,分为DIC组17例、非DIC组20例,正常对照组20例,所有患者均行常规凝血功能、血常规及TEG检测。应用ROC曲线对TEG各指标进行分析评价。结果:1.严重脓毒症DIC组PLT显著低于非DIC组及正常对照组,PT、APTT显著高于正常对照组,差异有统计学意义(P<0.01)。严重脓毒症非DIC组PLT与正常对照组间差异无统计学意义(P>0.05),PT、APTT、FBG均显著高于正常对照组,差异有统计学意义(P<0.01)。2.严重脓毒症DIC组R时间、K时间显著高于正常对照组,α角、MA值及CI值显著低于正常对照组。严重脓毒症非DIC组K时间显著低于正常对照组,α角、MA值及CI值显著高于正常对照组,差异均有统计学意义(P<0.05)。3.R时间、K时间、α角、MA值、CI值的ROC曲线下面积分别为0.790,0.932,0.915和0.915,差异有统计学意义(P<0.01);以最佳诊断临界点计算各诊断指标的敏感度、特异度、阳性预测值、阴性预测值、阳性似然比、阴性似然比,结果显示各指标阴性预测值较高。结论:TEG可识别严重脓毒症的凝血状态,协助诊断严重脓毒症并发DIC,评估血栓、出血风险,并指导治疗。

Evaluation of coagulation disturbances with thromboelastography in patients with severe sepsis

Objective:To investigate the role of Thromboelastography(TEG)in the diagnosis of severe sepsis with DIC.Methods:Data of TEG and traditional coagulation assays were analyzed in 37 patients with severe sepsis.According to the criteria of overt DIC scoring system,the patients will be classified into two groups,DIC group and non-DIC group.Twenty healthy volunteers served as controls.Receiver operating characteristic curves(ROCs) were analyzed for main TEG parameters.Results:1.Compared with healthy controls,all traditional coagulation assays except blood platelet count revealed a significant change toward coagulopathy in patients with severe sepsis without DIC(P<0.01 for all).In DIC patients,the deviation was even stronger,including a reduction in platelet count(P<0.01 in comparison with both controls and patients without DIC).Only plasma fibrinogen concentration did not differ in patients with DIC and healthy controls,but it was increased in patients with severe sepsis without DIC(P<0.01).2.In patients with DIC,reaction time(R time),kinetics(K time),α angle,maximum amplitude(MA) and coagulation index(CI) differed from that in both healthy controls and patients without DIC,indicating hypocoagulation.In patients without DIC,K time,α angle,MA and CI indicated hypercoagulation(P<0.05 for all).3.Receiver operating characteristic curves showed that R time,K time,α angle,MA and CI discriminated patients with overt DIC moderately(area under curve 0.790,0.932,0.915 and 0.915,respectively,P<0.01 for all).The negative predictive values of K time,α angle,MA and CI were high at the point of the best accuracy.Conclusion: Hypocoagulation in patients with severe sepsis and DIC,hypercoagulation in those with severe sepsis without DIC could be differentiated by TEG.TEG may be a valuable tool in diagnosing severe sepsis with DIC and therefore in guiding clinical therapy.